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Medical Policy Revision: Genetic Testing for Cardiac Ion Channelopathies

Effective April 1, 2021, Horizon BCBSNJ will change the way we consider certain professional claims based on a revision to our medical policy, Genetic Testing for Cardiac Ion Channelopathies.

Access our Medical Policy Manual to review this medical policy content.1

Genetic testing claims related to genetic testing to determine future risk of Long QT syndrome (LQTS) provided on and after April 1, 2021 will be processed as noted below.

  • We will continue to request information to help us determine the medical appropriateness of the services represented by CPT® codes 81403, 81405, 81406, 81407, 81408, 81413, 81414, 81479, and HCPCS code S3861.

    If the information received indicates that genetic testing services were performed to determine future risk of LQTS in an asymptomatic member with a relative diagnosed with LQTS by clinical means whose genetic status is unavailable, the services represented by the codes above will be denied as experimental/investigational, noncovered services.

  • As we are moving to more restrictive guidelines than exist in our current criteria, there is a potential for an increased number of denials of genetic testing of asymptomatic individuals to determine future risk of LQTS.

This revision impacts all Horizon BCBSNJ members (except as noted below), including those members enrolled in plans that participate in our Molecular and Genomic Testing Program administered by eviCore. You can access the molecular and genomic diagnostic laboratory testing guidelines that apply to members enrolled in plans that have elected to participate in our Molecular and Genomic Testing Program.

This policy revision will not impact claims submitted for services provided to patients enrolled in the following programs/plans/products:

  • BlueCard® (please contact the member’s local BCBS Plan regarding requirements)
  • Federal Employee Program® (FEP®)

The content of Horizon BCBSNJ medical policies that apply to members enrolled in Medicare Advantage plans may include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). We follow Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and/or LCDs in our processing of claims for services provided to our MA members. For those services where no LCD or NCD exists, claims for MA members will be processed based on our policy guidelines.

eviCore healthcare is an independent company that supports Horizon BCBSNJ in the provision of Prior Authorization and/or Medical Necessity Review (PA/MND) of certain molecular and genomic diagnostic testing services that are rendered in a physician’s office or clinical laboratory setting. eviCore Healthcare is not affiliated with Horizon BCBSNJ or the Blue Cross Blue Shield Association. eviCore healthcare is a registered trademark of eviCore healthcare

CPT® is a registered mark of the American Medical Association.

Published on: December 31, 2020, 00:35 a.m. ET
Last updated on: May 6, 2021, 02:56 a.m. ET